Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
BACKGROUND:
Cardiovascular risk factors are common and poorly controlled in patients with diabetes. Moreover, recent data suggest that only 12.2% of individuals with diabetes achieve simultaneous control of their blood pressure, glycemia, and lipids. A method that has been used previously to improve risk factor control is case management using physician extenders (e.g., nurses, pharmacists). This randomized study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Veterans with elevated values for BP, LDL, or HbA1c, who had received care within the Minneapolis VA Health Care System were recruited for the study between 9/06 and 4/08. Patients in the nurse case management intervention group (n=278) discussed lifestyle management goals (e.g., weight loss, smoking cessation) and personal action plans were developed. Over the 12-month study period, nurse case managers contacted patients to review self-monitoring of glucose and BP – and to make medication adjustments, as needed. Veterans in the usual care group (n=278) were asked to continue managing their diabetes, BP, and lipids under the direction of their primary care provider. The primary outcome was the percent of patients with control of all three CVD risk factors, defined as BP <130/80, LDL<100mg/dL, and HbA1c<8.0%. Secondary outcome measures included the number of Veterans achieving individual treatment goals at one year.
FINDINGS:
- Involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group (22% vs. 10%).
- In addition, a greater number of Veterans in the nurse case management group achieved the individual treatment goals compared to Veterans receiving usual care: BP<130/80 (41% vs 16%), HbA1c<8.0% (41% vs. 25%), LDL<100mg/dL (41% vs. 28%).
- Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
LIMITATIONS:
- While the overall intervention demonstrated a benefit, it is unclear what component of the study intervention resulted in the benefit, as individual components were not evaluated separately.
- There were few women and minorities enrolled, which is typical of the VA patient population.
- Investigators did not examine differences in the number of patient contacts and FTE case manager time required by the intervention vs. usual care.
AUTHOR/FUNDING INFORMATION:
This study was funded by VA (through VISN 23). Drs. Greer and Taylor are part of HSR&D’s Center for Chronic Disease Outcomes Research, Minneapolis, MN.
Ishani A, Greer N, Taylor B, et al. Effect of Nurse Case Management Compared to Usual Care on Controlling Cardiovascular Risk Factors in Patients with Diabetes: A Randomized Controlled Trial. Diabetes Care June 2, 2011;E-pub ahead of print.
